Malnutrition in long-term care: Diagnosis, treatment, and MDS coding 

Malnutrition in long-term care is widespread and detrimental as it considerably increases morbidity and mortality among those who are affected. Registered dietitians play a key role in how malnutrition is addressed including being an important part of the diagnosis, treatment, and documentation on the Minimum Data Set (MDS). This ensures residents receive quality care and the facility receives proper reimbursement.   

Understanding malnutrition

Malnutrition is defined as an imbalance between the nutrients the body needs to function and the nutrients it is receiving. There are different types of malnutrition including undernutrition or overnutrition. Malnutrition can be due to inadequate calories or protein consumed or can be attributed to poor nutrient absorption and utilization. In the case of overnutrition, the body deals with the excess calories and nutrients that are consumed. For the purposes of this article, we will be focusing on malnutrition due to undernutrition. 

How malnutrition develops

Malnutrition can be caused by factors such as inadequate food intake, poor diet quality, increased energy needs due to acute or chronic illness, poor nutrient absorption related to a digestive disorder, or a combination of two or more of these factors.  

Malnutrition among long-term care residents most commonly occurs when the resident is not consuming adequate calories, protein. This sort of undernutrition is typically characterized by weight loss and a decline in physical function. Residents may feel more fatigued doing normal activities of daily living, or they may begin experiencing falls. These residents may also suffer from poor wound healing or new skin breakdown.   

When residents are not consuming enough food, they may experience vitamin and mineral deficiencies. Common micronutrient deficiencies among older adults include vitamin D, vitamin B12, and iron; the latter can manifest in iron deficiency anemia.  

Malnutrition can also develop when a resident has an underlying medical condition that affects nutrient absorption or metabolism. Examples of these existing conditions are digestive disorders, chronic illness, metabolic disorders, and infectious diseases.   

Risk factors for developing malnutrition

In most cases, malnutrition in the long-term care setting is multifactorial. Some common factors that contribute to the condition are: 

• Underlying chronic diseases such as cancer, diabetes, and GI disorders 
• Cognitive impairments such as dementia, traumatic brain injury, or multiple sclerosis 
• Depression or other metal health conditions 
• Functional limitations such as physical disabilities or swallowing issues 

These conditions should be considered risk factors for malnutrition and may require early nutrition interventions and close monitoring by the dietitian.  

Malnutrition diagnosis and MDS coding

During nutritional assessment and follow-ups, the following signs and symptoms are clues that indicate a diagnosis of malnutrition may be present. 

• Weight loss 
• Decreased handgrip strength 
• Muscle wasting 
• Poor wound healing 
• Impaired immune function 
• Changes in hair, nails, and/or skin 
• Changes in functional status 

A nutrition-focused physical exam (NFPE) is used in combination with an evaluation of weight history and meal intake to determine the presence of malnutrition and should be documented and coded appropriately on the MDS.  

The coding related to malnutrition on the MDS should be interdisciplinary with the dietitian’s input being an integral part. The dietitian is responsible for documenting information related to height and weight (K0100), nutritional approaches (K0200), weight loss in the last 30 days (K0300), swallowing problems (K0510), and nutrition status (K0710).  

Documentation requirements and MDS completion can vary from facility to facility based on procedures established by the individual facility. Best practice is becoming familiar with the MDS guidelines and your facility’s policies.   

Patient Driven Payment Model (PDPM)

 The PDPM is a reimbursement system implemented by the Centers for Medicare and Medicaid Services (CMS) for Medicare Part A in skilled nursing facilities. This system is designed to determine payment based on various clinical characteristics including information related to malnutrition, dehydration, and other nutritional concerns.  

 This system is important to dietitians for several reasons including its focus on resident-centered care, interdisciplinary collaboration, and advocacy for nutrition care. Resident-centered care is geared towards allowing the dietitian to provide the best individualized care to a resident, which in turn, increases patient outcomes. Interdisciplinary collaboration is vital for an accurate diagnosis of malnutrition based on a comprehensive evaluation of the resident. Advocacy for nutrition care helps reinforce the importance of the dietitian in the long-term care setting. Dietitians can address malnutrition in a timely manner, implement preventative nutrition interventions, and monitor for any changes needed to the care plan.  

Treatment and prevention of malnutrition

Treatment and prevention of malnutrition by the dietitian can contribute significantly to the overall health and well-being of a resident in long-term care. Starting with prevention, the following should be considered as important screening tools to identify at-risk residents. 

• Routine nutrition risk screening 
• Dining programs 
• Nutrition education 
• Regular monitoring and nutrition assessments 

A solid treatment plan should be established when malnutrition is identified and diagnosed. This may include: 

• Nutrition assessment 
• Individualized care plan 
• Diet modification 
• Nutritional supplementation  
• Interventions and monitoring 
• Interdisciplinary collaboration 
• Diet education and counseling 

Conclusion

Addressing malnutrition in long-term care can be challenging and requires a collaborative approach. Registered dietitians can drive the process and play a vital role in identifying, treating, and preventing malnutrition as well as coding appropriately to ensure proper reimbursement for the facility. The ultimate goal is to improve a resident’s overall health and quality of life. 

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References: 

Prevalence of Malnutrition Among Older Adults in a Population-Based Study- the HUNT Study. Available at https://www.sciencedirect.com/science/article/pii/S2405457723012135. Accessed on 12/14/23. 

Overnutrition: Current Scenario and Combat Strategies. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6755771/#:~:text=Overnutrition%20is%20a%20form%20of,%2C%20overweight%2Fobesity)1. Accessed on 12/14/23. 

Malnutrition. Available at https://my.clevelandclinic.org/health/diseases/22987-malnutrition. Accessed on 12/14/23. 

Malnutrition: What You Need to Know. Available at https://www.medicalnewstoday.com/articles/179316. Accessed on 12/14/23. 

Malnutrition Diagnosis and the Value of an Experienced Registered Dietitian Nutritionist. Available at https://www.beckydorner.com/diagnosing-malnutrition-with-registered-dietitian-nutritionist/. Accessed on 12/16/23. 

Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings. Available at https://www.sciencedirect.com/science/article/abs/pii/S2212267218301540. Accessed on 12/16/23.